Guidelines for the Physiotherapy management of older ...

1 1 Guidelines for the Physiotherapy management of older people at risk of falling agile : Chartered Physiotherapists working with older People Produced by the agile Falls Guidelines working group: Victoria Goodwin & Louise Briggs August 2012 2 Since the publication of the Guidelines for the rehabilitative management of elderly people who have fallen 1 there has been a wealth of new research evidence, national and international Guidelines relating to the prevention of falls in older people. This update to the Guidelines is intended to provide a Physiotherapy focussed summary of the current evidence and to supplement Chartered Society of Physiotherapy and agile Standards of Practice.

2 Evidence supports the provision of Physiotherapy interventions, such as exercise, as part of a uni-professional service, or, as part of a multi-disciplinary team, undertaking multi-factorial assessments and tailored interventions. Practice points to consider: Establish the extent to which older people and their carers are able to participate in a falls prevention programme. Establish baselines of appropriate outcome measures as part of a pre-intervention assessment, against which ongoing or post-interventions outcome scores can be compared. This will enable an evaluation of the impact of any interventions, taking into account other plausible explanations for observed changes over time.

3 Patient goal setting (as opposed to therapy goals) should form part of any rehabilitation programme. Short and longer term SMART goals should be identified (Specific, Measurable, Achievable, Realistic, Timed). Physiotherapists should employ strategies for o motivating older people to actively participate in rehabilitation programmes, and o promoting adherence, whilst taking into consideration patient beliefs, attitudes and preferences2. When planning falls prevention programmes, supplementary interventions for bone health should also be considered for those older people at risk of fragility fracture, such as bone loading exercises, nutrition and medication.

4 This may involve other members of the multi-disciplinary team or fracture liaison service. The provision of mobility aids should not be undertaken in isolation and should always form part of a broader rehabilitation programme including strength and balance training. Where current evidence for the effectiveness of interventions is inconclusive or absent, physiotherapists should make clinical decisions relating to the care of an individual patient based upon the best available evidence, in conjunction with contextual factors and information obtained during subjective and objective assessment of the individual.

5 3 Aim 1: To prevent falls Assessment including outcome measurement older people should be routinely asked whether they have fallen in the past year and asked about the frequency, context and characteristics of any falls2. management In a Cochrane systematic review, multi-component exercise programmes (home and group delivered) and Tai Chi have been found to reduce falls among community-dwelling older people3. Exercise programmes may be delivered as a single intervention or as part of a multi-factorial intervention. Programmes should be delivered by qualified health professionals or exercise professionals, tailored to the individual, and, should include regular review, progression and adjustment of the exercise prescription as appropriate4.

6 Systematic reviews by Sherrington and colleagues regarding exercise interventions to reduce falls reported the most effective programmes included a high balance challenge, used a higher dose of exercise (50 hours- roughly twice a week for six months) and did not include a walking programme5;6. The effectiveness of exercise interventions for preventing falls among people with stroke7 and Parkinson s disease8 is inconclusive. Neither exercise nor multi-factorial interventions appear to be effective at reducing falls among people with cognitive impairment4. In nursing care facilities, the effectiveness of exercise interventions is uncertain although supervised exercise programmes are effective in sub-acute hospital settings9.

7 Multi-factorial interventions (which may include exercise) appear to be effective at reducing hospital falls and may be effective with people in nursing homes9. Key messages Assess falls history over the past year Exercise interventions can be delivered as a single intervention or as part of a multifactorial intervention Exercise programmes to reduce falls should be high dose (> 50 hours over 6 months) Exercise programmes to reduce falls should have a high balance challenge component 4 Aim 2: To improve the older person s ability to withstand threats to their balance Balance impairment is a major risk factor for falls among older people and those with long term conditions, such as stroke or Parkinson s disease10;11.

8 Assessment including outcome measurement older people reporting a fall or considered at risk of falling should be observed for balance and gait deficits and considered for their ability to benefit from interventions to improve strength and balance4. Assessment should identify risk factors relating to balance and mobility limitations, such as muscle strength and gait, and establish which factors are modifiable with exercise or rehabilitation interventions. There are a wide range of outcome measures for assessing balance. When selecting an outcome measure, consideration should be taken in relation to the properties of the measure (reliability, validity, sensitivity to change).

9 Measures you may consider include: Berg Balance Scale Timed Up and Go Test Performance-Orientated Mobility Assessment 180 degree turn Four-square step test management A recent Cochrane systematic review12 examining exercise interventions to improve balance among older people reported exercise interventions that included: (a) gait, balance, coordination and function training; (b) strength training; (c) three dimensional training dance, tai chi; and (d) mixed training were beneficial in relation to balance outcomes. The most effective programmes involved dynamic exercise programmes that ran three times weekly training for three months.

10 Key messages Use appropriate reliable and valid outcome measures Include exercise components for gait, balance, coordination and function Include strength training and three dimensional activities Ensure balance training is sufficiently dynamic 5 Aim 3: To prevent the consequences of a long lie Up to half of non-injured fallers are unable to get up again13;14. The inability to get up from the floor independently following a fall is associated with subsequent serious fall-related injury15;16 and increased mortality14. The consequences of a long lie on the floor (> 1 hour) include pressure sores, hypothermia and dehydration and increased risk of admission to hospital with a subsequent fall, or moving into long term care17.